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Disruption and infection of median sternotomy wounds are grave complications often associated with prolonged hospitalization, high cost, and significant mortality. Effective prevention techniques are still debated. Successful management requires early recognition based on a high index of suspicion, detailed physical examination, appreciation of the clinical signs and symptoms, timely imaging studies, and prompt surgical therapy. Improvements in perioperative management and critical care of patients with multisystem organ failure can reduce morbidity and mortality rates. Sternal salvage and direct sternal reclosure are possible when the infection is diagnosed early. Techniques utilizing lateral sternal support should be first-line options in the condition. Muscle flap techniques should be the next consideration when direct closure has failed or cannot be attempted.

Understanding the biomechanics of midline sternotomy repair is important to successful surgical outcome. High-risk patients, particularly those with immunosuppression, diabetes, and osteoporosis, should be identified. Details of technique should be monitored, and closure should incorporate lateral support of the sternum in patients at risk. Sternal dehiscence can occur under physiologic loads. Closure techniques and materials should insure stable repair, with avoidance of material migration through the bone.

Traumatic hernia resulting from blunt impalement of the abdominal wall, known as "handlebar hernia," is seldom addressed in the surgical literature, with only 28 previously reported cases. We describe our experience with this rare traumatic hernia diagnosed by physical examination and confirmed by ultrasonography. Published reports suggest handlebar hernia's potential for serious underlying injury and the diagnostic importance of computed tomographic scanning. The case presented here demonstrates the value of bedside ultrasonography in diagnosis confirmation and surgical planning for this condition.

Background: The initial prognostic classification of a pathologic event has important implications for management, outcome, and resource utilization. A variety of prognostic classification methods have been developed, but none has thus far shown consistent predictive accuracy in individual patients. In an attempt to overcome some of the limitations encountered by earlier workers, we have developed a simplified system for evaluation and prognosis of acute pancreatitis., Materials and Methods: We studied retrospectively 306 patients with acute pancreatitis. Nonstandard statistical calculations were used to create risk indices for pancreatitis severity for all 13 variables which were included in a standard chart., Results: The risk assessment rule's correct prediction is 81.32% (sensitivity) and 93.95% (specificity) for severe and mild pancreatitis, respectively. The total accuracy is 90.20%., Conclusion: The results of this nonstandard small retrospective study seem promising. It should remain experimental until larger prospective studies confirm the usefulness of the method., (Copyright 2001 Academic Press.)

Background: We present our experience with a unique type of foreign body that was specifically designed to arrest in its passage and cause perforation of the gastrointestinal tract., Study: Between 1994 and 1999, nine male prisoners from the same jail presented after ingestion of "crosses." A cross is constructed from the two halves of a standard paperclip that are tied together with a rubber band. The resulting construction is elastic: the two branches can be pulled to lie parallel, but they assume their original position once released. The cross is wrapped into paper with its branches parallel and ingested. After release from the wrapper, it "opens" and causes bowel perforations., Results: All patients underwent emergency surgery for foreign body removal and treatment of peritonitis. A total of 19 crosses were removed from the patients. Six (32%) were found in the stomach; five, in the duodenum (28%); three, in the jejunum and ileum (16%); and one, in the pylorus and colon. There was no morbidity or mortality., Conclusions: Foreign bodies of this type never pass distally. The ultimate key to success in the management of patients who have ingested crosses is emergency surgical intervention.

Spigelian hernia is considered a surgical rarity. Recent articles describe only six recurrent hernias and a scant number of patients with colonic obstruction resulting from incarceration. A patient with intestinal obstruction resulting from recurrent Spigelian hernia with strangulated colon is described. The patient underwent tension-free repair using a prosthetic mesh. Recent literature suggests that the deficiency of connective tissue in patients with hernias justifies the widespread use of permanent mesh for tissue reinforcement and avoidance of recurrences. The rare case presented should be regarded as an illustrative example for application of the tension-free repair principle in the definitive management of recurrent Spigelian hernia.

Meckel's diverticulum is the most common congenital abnormality of the small intestine. A case of Meckel's diverticulum duplication is described, believed to be the first report of this kind in the literature.

We describe a unique case of combined thoracic and subcutaneous splenosis.

Background/aims: Idiopathic perforation of the small intestine is extremely rare. The definition depends on the absence of any detectable pathology that could be responsible for the perforation. This study was undertaken to outline the criteria for determination of the condition., Methods: Case report and review of the literature., Results: A 50-year-old male patient underwent surgery including laparostomy and planned reexplorations for multiple recurrent small intestinal perforations of unknown origin; the patient made an uneventful recovery. Extensive investigations were carried out to search for any pathology that could explain the occurrence of perforations, but yielded no results., Conclusions: Further studies will possibly give more information concerning idiopathic perforation of the small intestine, provided that judicious criteria for its determination are applied., (Copyright 2000 S. Karger AG, Basel)

Gaining access to deeply located hydatid cysts of the liver using conventional surgical techniques may be accompanied by significant intra- and postoperative complications. In addition, obliteration of the cyst cavity is still a matter of controversy. We developed a novel method for easy access to deep hydatid cysts using a water jet dissector (Parenchimotom 01, TOSA, Pleven, Bulgaria). At pressure of 20 Bar using a 0.2 mm nozzle, a corridor is created through the liver parenchyma overlying the cyst; vessels and biliary duct are thus clearly displayed as linear structures traversing the corridor and are ligated and divided under direct visual control. The fibrous capsule of the cyst is spared by the jet. Following endocystectomy performed in the ordinary manner, the cyst cavity is filled with gelatin sponge; a passive tube drain is placed in contact with the liver incision. In allowing for a selective dissection of the liver parenchyma, the jet makes safe access to deeply located hydatid cysts possible. On the other hand, the gelatin sponge induces good fibroblast response and assists in rapid and effective obliteration of the residual cavity. This novel technique works well in our hands but more extensive studies are necessary before its final acceptance.

Purpose: We describe the successful application of a water jet to reconstructive renal surgery., Materials and Methods: Two consecutive patients underwent reconstructive renal surgery using a waterjet apparatus for a 4.0x6.5 cm. well encapsulated tumor of the lower pole of the left kidney and a 4.5x2.5 cm. staghorn calculus of the left kidney, respectively. The water jet apparatus (Parenchimotom 01) consists of a pressure generating pump and a flexible hose connected to the hand piece, and a nozzle with a pinhole opening of 0.3 mm., Results: Both patients underwent surgery through a left lumbar incision. Partial nephrectomy was performed in 1 patient and anatrophic nephrotomy for stone removal in the other. Dissection time was 25 and 12 minutes, with blood loss of 150 and 100 ml., respectively. No temporary vascular clamping or local hypothermia was necessary. Both patients were discharged home 10 days after surgery and at followup no negative sequelae were attributable to the procedure., Conclusions: The operative procedures proved easy, fast and effective. No temporary vessel clamping or hypothermia was required. Using a water jet is a novel approach that is helpful in renal surgery.

A patient is described who was found to have both eosinophilic enterocolitis and visceral neuropathy with chronic idiopathic intestinal pseudo-obstruction. The etiology and pathogenesis of this rare combined disorder of the gastrointestinal tract are discussed. Although eosinophilic enterocolitis is amenable to conservative treatment, surgery may be necessary for palliation in selected patients with pseudo-obstruction due to visceral neuropathy.